Grand Rounds Archive

Grand Rounds November 8, 2024: The Effect of Cash Benefits on Health Care Utilization and Health: A Randomized Study of an Income Support (Sumit Agarwal, MD, MPH, PhD)

Posted on by Sophia Ramirez

Speaker

Sumit Agarwal, MD, MPH, PhD
Assistant Professor
Division of General Medicine
University of Michigan

Keywords

Income Support; Cash Benefits; Low-Income Population

Key Points

  • Low-income patients face several barriers to care and achieving better health. Co-pays prevent people from filling prescriptions; transportation barriers prevent patients from attending appointments; emergency departments take the place of primary care; and people cope with anxiety, depression, and/or substance use amid economic vulnerability.
  • The research team sought to understand the effect of income support on health care utilization and health. They conducted a randomized controlled study of a cash benefit program led and implemented by the government of Chelsea, Massachusetts.
  • Several features of the intervention made it uniquely suited to understanding the effect of income: it was recurring; it was a large amount relative to the baseline income in the community, which was around $1,500 per month; it was unconditional; there were no restrictions on how the money could be spent; and it was randomized.
  • The research team assembled electronic health record (EHR) data from three major health systems in the Boston area. Participants were linked to their EHR records. Together, this data likely accounts for 77% of all acute care and 78% of all outpatient visits among Chelsea residents.
  • Their primary outcome was the number of emergency department (ED) visits. Their secondary outcomes included ED visits by type; outpatient use; clinical measures; and COVID vaccination.
  • The research team found a 27% reduction in emergency department visits, including hospitalizations, and a 21% increase in subspeciality care. There was no change in clinical measures nor in COVID vaccination rates.
  • These findings raised two questions: 1) Were people utilizing the emergency room less because they were increasingly able to access and utilize outpatient care? 2) Given the decrease in emergency department use and hospitalizations, are there potential cost savings here?
  • Dr. Agarwal suggested that substitution was likely not driving the decrease in emergency department utilization, noting that there was no change in the rate of primary care or urgent care visits, nor in prescriptions; the decrease in emergency department visits and increase in subspecialty care appeared in two distinct groups of people.
  • The study team estimated that the decrease in acute care utilization resulted in savings of $450/person for the healthcare system. When discussing the cost of running a cash benefit program, Dr. Agarwal noted, it is important to acknowledge potential offsets as well.

Discussion Themes

The collaboration with the city of Chelsea simplified funding; the road to IRB approval; and obtaining community engagement and buy-in.

Cash transfer programs in the U.S. tend to fall in one of two categories: Programs that target certain low-income populations, i.e. families with children, and, increasingly, programs that target patients with substantial barriers to healthcare, i.e. pediatric cancer patients. Both will yield insights into how we can target a cash transfer intervention more broadly.

The effects were sustained in the months after the nine-month intervention period, albeit at slightly lower levels. However, it’s unlikely that this effect will be maintained in the long term; a one-time, brief cash infusion probably cannot overcome the cumulative disadvantages driving health disparities.

About 70% of the funds were spent at places where food was the primary product, namely grocery stores and markets. Roughly 20% were spent on retail; 4% on utilities; 1% on transportation; and 0.4% on alcohol and smoking. This represents a counterpoint to the concern often expressed about cash transfer programs: that the funds will be spent on tobacco and alcohol.

Grand Rounds November 1, 2024: Congenital Heart Initiative: Redefining Outcomes and Navigation to Adult Centered Care (CHI-RON) Study (Thomas W. Carton, PhD, MS; Anitha S. John, MD, PhD)

Posted on by Sophia Ramirez

Speakers

Anitha S. John, MD, PhD
Medical Director
Washington Adult Congenital Heart Program
Professor of Pediatrics
Children’s National Hospital
George Washington University

Thomas W. Carton, PhD, MS
Chief Data and Strategy Officer
Louisiana Public Health Institute

Keywords

Adult Congenital Heart Disease; Registry; Patient Engagement

Key Points

  • The research team reviewed the current challenges in adult congenital heart disease (ACHD) clinical care, surveillance, and long-term outcomes research, including a demand for subspecialty care that outweighs the supply; the heterogeneity of CHD and its long-term outcomes; and changing treatment strategies.
  • Though there are several CHD registries in the U.S., very few focus on adults with CHD. The research’s teams efforts, beginning with the Congenital Heart Initiative (CHI) launch in 2020, came about in response to this gap.
  • The mission of the CHI is to create a digital hub collecting health data from patients and providers. The team seeks to involve patients in every aspect of the CHI registry, with the ultimate goal of creating a community of ACHD patients and providers with a shared understanding of research needs and medical outcomes.
  • As the registry initially lacked data from healthcare providers and the electronic health record, the team partnered with PCORnet to establish an ACHD surveillance system.
  • The CHI-RON study uses PCORnet data and patient-reported outcomes to determine whether ACHD patients who are receiving recommended care do better than those who are not and the impact of gaps in care on patient-reported outcomes.
  • Dr. Carton provided an overview of PCORnet, followed by a review of the data science innovations the team used to generate a computable phenotype, identify congenital heart providers, diversify demographic recruitment for the registry, and incorporate procedure results into the common data model for analysis.
  • One of the strengths of this project was the high degree of patient and partner engagement. This involvement led directly to programming such as the “ACHA Café,” a virtual coffee hour in which patients could engage with one another, and guided their social media content.

Discussion Themes

The ACHD patient population identified a few key topics that they hoped the CHI would explore, including long-term effects of congenital heart defects, the most effective therapeutics for treating CHD, and mental health care options. Patient partner feedback also helped the team refine their recruitment and outreach materials.

Given the tendency for some types of CHD to be given more attention than others, the research team sought to enroll a patient population that was inclusive of a variety of presentations. This presented some methodological challenges, e.g. when it came to drawing distinctions in the registry.

Grand Rounds October 25, 2024: How Hybrid Working From Home Works Out (Nicholas Bloom, PhD)

Posted on by Sophia Ramirez

Speaker

Nicholas Bloom, PhD
Professor of Economics
Stanford University

Keywords

Remote Work; Hybrid Work; Job Performance; Attrition

Key Points

  • Dr. Bloom conducted a randomized controlled trial at the Trip.com headquarters in Shanghai to test the efficacy of a hybrid WFH model. 1,612 employees in the IT and Airfare divisions were randomized to come into the office either five days/week (the control arm) or three days/week, with the option to work remotely on Wednesdays and Fridays (the intervention arm).
  • The research team collected attrition and performance data during the six-month intervention period and 18-month follow-up period.
  • Over the six-month intervention period, quit rates were 33% lower in the treatment group than in the control group. The impact on attrition varied by group, with the greatest improvements among non-managers, women, and employees with long commutes. Satisfaction survey results were also more positive within the treatment group.
  • They found that hybrid WFH had no impact on performance reviews, promotion rates, or lines of code written. At the outset, managers were skeptical of the effect hybrid WFH would have on productivity; over the course of the trial, however, their attitudes became more favorable.
  • In the interest of reducing costs incurred by turnover, the company rolled out the hybrid WFH option to all employees shortly after the trial concluded. The research paper is open-access; read it in Nature.

Discussion Themes

To maximize the success of the hybrid WFH model, employees should coordinate the days that they come into the office with their colleagues and employers should base the number of days they allow people to work from home on their capacity to measure performance.

Though employees worked slightly fewer minutes on average on WFH days, taking advantage of the increased flexibility to pick up children, go to appointments, etc., they made up for that time by working more minutes on in-office days and on weekends.

There are tradeoffs involved in the decision to WFH: Though an employee may have more flexibility and even be more productive, they may also be less likely to get promoted compared to peers that are working in-person.

Going forward, Dr. Bloom predicts the percentage of hours worked from home will continue to increase due to three practical factors:

  1. Leases are expiring, and as they expire, companies will downsize to save money on real estate.
  2. Younger executives are more in favor of WFH.
  3. The technology is improving, making it easier and cheaper to WFH.

Grand Rounds October 18, 2024: Rigorous Testing of Behavior Change Interventions: Lessons from the BE ACTIVE Randomized Clinical Trial (Alexander Fanaroff, MD, MHS)

Posted on by Sophia Ramirez

Speaker

Alexander Fanaroff, MD, MHS
Assistant Professor of Medicine
Perelman School of Medicine
University of Pennsylvania

Keywords

Gamification; Financial Incentives; Physical Activity; Behavioral Economics

Key Points

  • Observational studies have found an inverse association between steps per day and risk for all-cause mortality and cardiovascular events. Though national surveys indicate the vast majority of people believe that exercise has many health benefits, many don’t exercise.
  • Behavioral economics seeks to explain why people make the decisions they do using concepts from economics and psychology. Dr. Fanaroff discussed how known biases in decision making – immediacy bias, status quo bias, and the endowment effect – create a disconnect between the “planner” self and the “doer” self. This framework can be used to understand why people don’t exercise, even when they know they should.
  • Another barrier that the research team identified was that existing guidelines from the American College of Cardiology and American Heart Association lack specificity and strong supporting evidence. Dr. Fanaroff ultimately introduced an alternative recommendation based on their findings.
  • The research team sought to leverage our existing biases in order to facilitate a sustained increase in physical activity. In a randomized controlled trial, they compared the effectiveness of gamification, financial incentives, and a combination of the two on increasing physical activity over a 12-month intervention period and a 6-month follow-up period.
  • After noting a discrepancy between the proportion of Black patients in the target population and participant population, the research team adjusted their recruitment strategy until they had a representative group. While direct-to-patient recruitment avoids biases related to who physicians invite to clinical trials, it may introduce biases related to who trusts researchers enough to join a study.
  • The research team found that gamification and financial incentives were roughly equally effective, leading to about 500 more steps per day than the control group. The combination arm saw the biggest improvement, with about 850 more steps per day than the control group. In practice, gamification is the more scalable and inexpensive of the interventions.
  • If stakeholders are to pay for an intervention like this, large scale clinical trials are needed to show improvements in patient-centered outcomes or clinical events.

Discussion Themes

Pharmaceutical interventions are not expected to be effective once treatment has ceased. If a behavioral intervention is shown to be effective during the period in which it’s administered, should it be held to a standard of long-term sustainability?

Patients set their own step count goals according to their baseline when the trial started.

The components of the intervention guided by behavioral economic theory, i.e. the immediacy of the innovation, the loss (rather than gain) of cash and/or points, and the support partners, differentiates it from the gamification built in to many wearables and fitness trackers.

Grand Rounds October 11, 2024: Early Diagnosis and Treatment of Asthma and COPD (Shawn Aaron, MD)

Posted on by Sophia Ramirez

Speaker

Shawn Aaron, MD
Professor
University of Ottawa

Keywords

Respiratory Symptoms; Guideline-Directed Care; Standard Care; Phone Recruitment; Randomized Controlled Trial

Key Points

  • Up to 70% of individuals with asthma or Chronic Obstructive Pulmonary Disease (COPD) remain undiagnosed. The 2007 – 2012 U.S. National Health and Nutritional Examination survey of randomly selected American adults found obstructive lung disease in 13% of the sample, 71% of whom had never been diagnosed.
  • Inspired by an encounter with a patient who had undiagnosed asthma, Dr. Aaron and his team developed three research questions for the Undiagnosed COPD and Asthma in the Population, or UCAP, study: 1) Can we find adults with undiagnosed asthma or COPD in the community? 2) Are they sick? 3) Can we treat them early to improve health outcomes?
  • They used a case-finding approach to identify symptomatic individuals with undiagnosed cases of either disease. Case-finding evaluates subgroups of people at increased risk of a disease; in this case, they looked at adults with undiagnosed respiratory symptoms.
  • To identify that sample, the team called over 1.1 million Canadian residents. After initial screening of the 50,000 contacts who indicated that there was someone in the household with respiratory symptoms, 2,857 of 4,272 eligible participants underwent testing with spirometry. A fifth of the sample had undiagnosed asthma or COPD.
  • Compared to a healthy age- and sex-matched control group, the adults with undiagnosed COPD or asthma had lower quality of life, worse symptoms and health status, and significant work impairment.
  • To determine whether early diagnosis of previously undiagnosed symptomatic asthma or COPD, and subsequent treatment, improves health outcomes, the team randomly assigned the participants diagnosed with asthma or COPD to the intervention or to usual care.
  • All participants and participants’ primary care providers (PCPs) were given a copy of their interpreted spirometry report with their diagnosis. The intervention group received treatment from a pulmonologist and an asthma/COPD educator; the control group received usual care from their PCP.
  • Guideline-directed treatment of undiagnosed COPD or asthma by a pulmonologist and an educator was found to improve healthcare utilization, symptoms, quality of life and lung function more than usual care.
  • In practice, not all patients can or will be treated by a lung specialist. The trial results indicated that the health of people with asthma or COPD will still improve if they are diagnosed and receive the usual care.

Discussion Themes

Cold-calling, though ultimately effective, was an expensive and inefficient screening and recruitment method. In the future, the team will attempt to drive people with respiratory symptoms to the study website by advertising in the community and on social media.

The research team considered a few iterations of the control arm, including a design in which the control group was informed of their diagnosis later on in the trial. They decided to compare guideline-directed treatment to usual care after reviewing the ethical considerations and the potential for inappropriate randomization.

Case-finding in a sample of people living in asthma or COPD “hotspots,” or in other high-risk populations, could increase the efficiency of the method but narrow the applicability of the findings.

Volunteer bias likely impacted the diversity of the sample; a disproportionate number of the volunteers were white (97%) and older, with an average age of 63.

Grand Rounds October 4, 2024: Health Trends Across Communities – A Novel Health System-Public Health Data Partnership (Tyler Winkelman, MD, MSc; David Johnson, MPH)

Posted on by Sophia Ramirez

Speakers

Tyler Winkelman, MD, MSc
Division Director, General Internal Medicine
Hennepin Healthcare
Co-Director, Health, Homelessness, and Criminal Justice Lab
HHRI

David Johnson, MPH
Health Informatics and Epidemiology
Program Manager
Hennepin County

Keywords

Electronic Health Record; Data Sharing; Public Health; Health Systems; Partnerships

Key Points

  • Collaboration across public health and health care is essential to developing actionable data for both sectors. Electronic Health Record (EHR) data can be used to fill the gaps in public health data and foster collaboration.
  • During the COVID-19 pandemic, it became clear that data infrastructure in the U.S. was underdeveloped. This made addressing COVID-19 challenging, is currently making addressing the overdose crisis challenging, and puts the country at risk for any future epidemics.
  • The Minnesota EHR Consortium (MNEHRC), formed in March 2020, facilitated collaboration between health systems in order to address gaps in COVID-19 data sharing and communication. They were able to develop the technical infrastructure to aggregate and share EHR data for real-time public health needs. Over time, the prioritization of data sharing for developing broader community health indicators became possible.
  • MNEHRC’s mission is to improve health by informing policy and practice through data-driven collaboration among members of Minnesota’s health care community. Dashboards are publicly available at www.mnehrconsortium.org.
  • Dr. Winkelman described how they built out a common data model at each of the MNEHRC health systems using Observational Medical Outcomes Partnership (OMOP), a common language for EHR data. OMOP was chosen because it’s open-source; it has a robust international online community; and some sites in the state had experience with OMOP, which helped with capacity building.
  • MNEHRC and Hennepin County’s Center for Community Health partnered to build Health Trends Across Communities (HTAC-MN), a unique data collaboration of health systems and public health agencies. They seek to develop comprehensive community health data infrastructure in Minnesota, ultimately strengthening community capacity to build healthy communities and promoting health equity.
  • Next steps for HTAC include developing and implementing processes to identify and prioritize new conditions; evaluating HTAC; and developing a plan for long-term sustainability.

Discussion Themes

Developing a central data model facilitated the collaboration.

Onboarding Federally Qualified Health Centers (FQHCs) to the consortium takes longer because of their internal capacity restraints. The team has had to be creative with figuring out how to onboard them; they are adding FQHCs in Hennepin County through EPIC affiliate agreements with Hennepin Healthcare and other sites through Minnesota’s quality measurement agency.

This is a new tool with a lot of potential, especially for the field of public health; researchers could use it to measure the impact of large-scale public health interventions. The HTAC team hopes that they’ll be able to further define the value that the data source can offer over the next few years.

Grand Rounds September 27, 2024: Azithromycin for Childhood Mortality: Randomizing Entire Countries (Thomas Lietman, MD)

Posted on by Sophia Ramirez

Speaker

Thomas Lietman, MD
Director
Francis I. Proctor Foundation
University of California, San Francisco

Keywords

Child Mortality; Antibiotics; Large Simple Trial

Key Points

  • Trachoma is a disease that affects the human eye, caused by infection with a strain of chlamydia. The scar tissue that is left behind warps the shape of eyelid, irritating the cornea and eventually causing full blindness. Antibiotics have been shown to reduce trachoma infection, with azithromycin being the preferred treatment.
  • Dr. Lietman described a series of mass azithromycin trials, including the “Azithromycine pour la Vie des Enfants au Niger: Implementation et Recherche” (AVENIR) trial in Niger and the “Macrolides Oraux pour Réduire les Décès avec un Oeil sur la Résistance” (MORDOR) trial in Niger, Tanzania, and Malawi.
  • In one of these trials, the mass distribution of azithromycin for trachoma control was shown to reduce the overall child mortality rate. The research team sought to test these findings in a younger age group (preschool-aged children) and with a larger sample size.
  • The MORDOR trial found that biannual azithromycin distribution reduced overall mortality in 1 – 59 month old children, though more so for the younger children. The WHO amended their guidelines to recommend administration of azithromycin in high mortality Sub-Saharan African settings to children 1 – 11 months old.
  • The release of the WHO guidelines was followed by the AVENIR trial, which – in addition to re-testing whether mass azithromycin distribution reduced childhood mortality in 1 – 59 month-olds – compared the reduction in mortality when treating only 1 – 11 month-olds as opposed to 1 – 59 month-olds. They also monitored antibiotic resistance.
  • The research team found that the 1 – 11 month-olds had significantly better outcomes in the latter treatment arm, in which children 1 – 59 months old received Azithromycin. The herd effect led to an indirect benefit for the younger children when the older children were treated.
  • The researchers successfully adapted toward the 1 – 59 month-old treatment group after 12 months, using a tempering algorithm to avoid dramatic swings in allocation probabilities.
  • They found that trachoma distributions and the childhood mortality distributions do select for macrolide resistance in a number of different bacteria, with resistance decreasing when the programs are stopped. Since they are only treating 1/6 of a population, there is less antibiotic pressure than with trachoma programs that treat an entire community.
  • AVENIR 2 will expand AVENIR to the entire country of Niger.

Discussion Themes

The ethical considerations of the trial were enormous and included consent and post-trial availability. It was very important for the research team A) to have strong, local collaborators and B) not to impose Western academic ways of thinking when partnering with these communities.

The researchers were mindful of the risk that, with adaptive trials, you can lose a treatment arm if you adapt too much early on. Retrospectively, Dr. Lietman noted, they were overly cautious when it came to tempering. Ultimately, everyone was treated by 24 months.

The team is hoping to eventually create a platform to monitor and coordinate treatment efforts between trials.

Grand Rounds September 20, 2024: Similarities and Differences Between Pragmatic Trials and Hybrid Effectiveness-Implementation Trials (John Fortney, PhD)

Posted on by Sophia Ramirez

Speaker

John Fortney, PhD
Professor
Department of Psychiatry and Behavioral Sciences
University of Washington
Senior Research Career Scientist
HSR Center of Innovation for Veteran-Centered and Value-Driven Care
VA Puget Sound Health Care System

Keywords

Pragmatic; Implementation; Hybrid-Effectiveness; Trial Types

Key Points

  • Pragmatic trials are primarily designed to determine the effectiveness of a clinical intervention under the usual conditions in which it will be applied. A hybrid-effectiveness implementation trial assesses both clinical effectiveness and implementation.
  • Dr. Fortney walked through the translational research pipeline, which flows from explanatory trials to pragmatic trials to implementation research. Ideally, the end product is improved processes and outcomes.
  • While the differences between explanatory, pragmatic, and implementation trials is well understood, the differences and similarities between pragmatic trials and hybrid type trials are not well understood.
  • Pragmatic Trials (PTs) and Hybrid Type 1 Trials (HT1) aim to test the effectiveness of clinical interventions, with patient outcomes as their primary outcomes. Hybrid Type 3 Trials (HT3) look at whether a given implementation strategy successfully promotes intervention uptake. Hybrid Type 2 Trials (HT2) compare two clinical interventions and one or two implementation strategies.
  • Whereas HT1s utilize artificial implementation strategies, PTs, HT2s, and HT3s utilize practical implementation strategies that they expect to be replicable outside of a research context.
  • Dr. Fortney provided resources, including a question tree and case examples, to aid researchers in identifying or choosing a trial type. He also provided several guidelines, including:
    • HT1 trial types should be used to determine whether a clinical intervention can be effective when delivered in routine care.
    • Pragmatic and HT2 trial types should be used to determine whether an evidence-based clinical intervention(s) is effective when delivered with practical implementation strategies in routine care.
    • HT2 and HT3 trial types should be used to determine whether practical and novel implementation strategies successfully promote the uptake of evidence-based clinical interventions.

Discussion Themes

The distinction between artificial implementation strategies and evidence-based, or practical, implementation strategies is not always black and white, and will often fall somewhere on the Artificial → Practical continuum.

This research team laid out some of the subtler differences in research objectives between study types, and the elements studies need to successfully address those objectives. Reviewers and researchers alike need to be careful in thinking these distinctions through and understanding them.

Grand Rounds September 6, 2024: Conventional, Complementary, and Integrative Pain Therapies in a Military Population with Chronic Musculoskeletal Pain: Results of a Pragmatic Clinical Trial Using SMART Design (Ardith Z. Doorenbos, PhD, RN; Diane M. Flynn, MD, MPH)

Posted on by Sophia Ramirez

Speakers

Ardith Z. Doorenbos, PhD, RN
Professor
Department of Biobehavioral Nursing Science
College of Nursing
University of Illinois, Chicago

Diane M. Flynn, MD, MPH
Primary Care Pain Management Advisor
Interdisciplinary Pain Management Center
Madigan Army Medical Center
Tacoma, WA

Keywords

Chronic Pain; Military; Rehabilitative Care; Pain Therapies; SMART Design

Key Points

  • Physical and occupational therapies are standard rehabilitative care (SRC) for chronic pain, and a growing body of evidence supports complementary and integrative health (CIH) therapies (such as acupuncture, chiropractic, yoga and massage).
  • Few studies have explored the optimal duration, sequence and combination of SRC and CIH to manage chronic pain.
  • The study team investigated the effectiveness of starting treatment for pain with SRC versus CIH therapies. Their primary outcome was the Pain Impact Scores of active-duty service members with chronic pain.
  • Their study design, a Sequential Multiple Assignment Randomized Trial (SMART) Design, randomized participants to CIH or SRC for three weeks each. At that point, participants who were improving continued on in their assigned treatment arm, while those who were not improving were randomized to either the other treatment arm or a combination arm.
  • Compared to baseline pain levels, both groups improved significantly up to six months out. After three weeks, the group that received SRT showed less improvement the group that received CIH therapies. However, by the end of the six-week mark, as well as at three- and six-month follow-ups, there wasn’t a significant difference in average improvement.
  • The study team’s ability to make assessments with regard to the duration of treatment is limited; participants were given the option to continue therapy for up to six weeks, so some were engaged in active therapy during the follow-up period.
  • These findings lend support to expanding access to CIH approaches. Clinicians can feel confident recommending patients start with CIH therapies if that is the patients’ preference.

Discussion Themes

Patients in the CIH arm and SRT arm received therapy for a total of 6.5 and 3 hours per week, respectively. At first blush, this indicates that a treatment hours effect could have contributed to the benefits seen in the first three weeks of the CIH arm; in practice, due to lower-than-intended participation, the actual treatment hours were only slightly higher in the CIH arm than the SRT arm.

Whether it’s caused by pain, combat experience, or adverse childhood experiences, many members of the study population experience a great deal of allostatic stress and kinesiophobia: “When I move, I hurt.” One of the study team’s theories as to why participants initially responded more positively to the CIH arm is that there was less movement involved.

Future directions may include examining the biological or neurological mechanisms underlying the interventions’ impact.

Dr. Flynn shared a resource that she noted would be helpful in defining SMART Designs and outlining some of the advantages and disadvantages:  https://jamanetwork.com/journals/jama/article-abstract/2800681

Grand Rounds August 23, 2024: Improving Quality of Life in COPD and Heart Failure: Unpacking a Successful Multicomponent Virtual Team Intervention (David B. Bekelman, MD, MPH; Lyndsay DeGroot PhD, RN, CNE)

Posted on by Sophia Ramirez

Speakers

David B. Bekelman, MD, MPH
Professor of Medicine and Psychiatry
Rocky Mountain Regional VAMC and University of Colorado Division of General Internal Medicine

Lyndsay DeGroot PhD, RN, CNE
Postdoctoral Fellow
University of Colorado
Anschutz Medical
Campus School of Medicine

Keywords

COPD; Heart Failure; Collaborative Care; Palliative Care

Key Points

  • Heart failure (HF) and Chronic Obstructive Pulmonary Disease (COPD) are common illnesses that share a number of symptoms, including persistent breathlessness and fatigue; depression; and anxiety.
  • Though HF and COPD patients could benefit from palliative care prior to the end of life, there aren’t enough palliative care specialists to provide care to the patient population.
  • ADAPT is a virtual intervention built on a collaborative care team approach. A nurse and social worker provide direct patient care and meet weekly with a collaborative care team – consisting of a primary care physician, palliative care specialist, and as-needed cardiologist and pulmonologist – to review individual cases.
  • The research team’s primary aim was to determine the effect of ADAPT on participant quality of life, measured using the FACT-G scale.
  • They concluded that a nurse and social worker palliative telecare team demonstrated early, persistent, clinically meaningful improvements in quality of life for high-risk outpatients with COPD, HF, and Interstitial Lung Disease.
  • The ADAPT virtual care model leveraged a team of nurses, social workers, and physicians across two large VA health systems to increase the reach of palliative care to common, serious non-cancer illnesses.
  • The intervention was relatively inexpensive, but implementing a multifaceted, personnel-intensive program posed its own challenges.
  • Future directions include investigating the intervention effect on utilization outcomes and end-of-life outcomes; adapting the model for patients with advanced liver or renal disease; testing other implementation and dissemination strategies; and investigating how to improve adoption.

Discussion Themes

The mortality rate in the population they enrolled was lower than expected. This may be because it is more difficult to enroll very sick patients from an outpatient population.

This study was designed to test the effect of the intervention on quality of life, an outcome that has a significant impact on patients. However, securing funding for work like this can be a challenge, as the program is not designed to reduce costs (unlike interventions that aim to reduce hospitalizations).

There is a need for creative solutions when it comes to funding this model; the research team is looking to collaboration with community partners and examples set by other, similar projects.